05080254 (4) CITY OF CUPERTINO rs I a a hxi Pence " p ''
BUILDING DIVISION PERMIT C0NTRACTORTNFURMATI0N
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BUILDING ADDRESS: ANTIQUE TERMITE & PEST PERMIT NO.05080254
OWNER'S NAME: PERMIT ISSUE DATE
MONIRA KAYANI 1913 STONE AVE
E: SANITARY NO. CONTROL NO.
408) 995-6300
ARCHTTECTIENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 t� 0 0
400 LICENSED CONTRACTOR'S DECLARATION
uyF 1 hereby AM.that 1 son lictmcd inti,provis au of Clupmr 9(commmming Job Description
n�S with Section 1000)of Division 3 of the Business and Profess dere Cod.mdmyl'remtacis
�m imfall fom.And IBM 2 (2) BATH SUBFL. /REPLACE KIT. PLUMB . FIXTURE
8z DAMLlomclot �" KITCHEN REMODEL
rt Dale Contractor
ARCHITECTS DECLARATION
I undraund my plans dull be used a public amNs
�d
O Lkenacd Professional
OWNER-BUILDER DECLARATION
Con77oN
I hereby.(firm oel 1 1. eusin from lire Croons o License Law for the
a o following requires
a permit
t ]11313,Business and Nvfdaduu Code:Any city s county
e
$�i which I"issuance,
remnswctpplicnt narrow.h Permit h me a sig Any structure
Fly pdormits ceased purse requires theapplicantforthe sucContractor's License
Neal Lmdnatrter9
< that Monacaant
isliunmdpumueminoepmvisimuofotCanuacorslJcentciaw(CbaPtm9 Sq.Ft.Floor Area Valll�'eip10075
$ (cot testis n{wiogempon100e)M basisofr ththeBed excnnd Prafou vi Cnde)of
- Rut he u...opt therefrom and the basis for Uta alleged gumption.My violation of
Section 7031.3 by any applicant two permit subjects the applicant to a civil pointy of APN Number Occupancy e
nal mart than Son hundred dollars(fM0\ p y�'F
35906037 . 00
❑I,ss owner of ded Property o is employees a,offered
weeds r their sole 044.Be men,
will dothe wark.andth The Com umis Liven a Law closer
font apply.t in owner
of Required Inspections
'
And property
Code:The Improves
tncmrt,License Law don not apply lf an owner of q p
property who builro m improves thereon,srod who daeumhwok Mmulf edderoujh his
own a however.
the n,provided Nutuh improvements ere mal ear of d mplealod fm moaner
however.the building orimprovementhe
n,Wild of comphtim.the (T1t7(T ry 1
build(aria have Br When of proving ore he did inti Wild or'unprose far purpose of LCtl1*s._tr(JJ'1u{'jjf��vjf#I� rf ED sada.). 11NWI�'Nh1�9_
❑1,u owner of Use property am exclusively contracting with licensed contmemss m
construct the project(See. 0".Business and Profession Cade:)The Commences U. �(OVg�y�
came Lew does not apply to an owner of property who Wilds or improve oeraw.and,
who conoscta for ueh projects with a conhacmr(0 num th [Vy y
licensed pu10 .C0MrMtora g 9005
License law. L �7
0 lam asemptundr Sec. B&PCTur Udsmomm r'Jyn
Date-
N UIL
Owner l hereby at an under proudly of pcqury0 a of Be,
fallowing -`�
dclarations:
1 haw end will maintain aConiOcnm of Cement toselfdnsum for Workers Compon-
snlon,u provided for by Bastian 3700 of the Labor Cod.for du per....of dm
wart f ieIt this permit is issued.
haw and will maintain Workees Compensation luurance,as acquired by Section
3700 of the labor Code,for the par(otmmec of the work for which this permit is issued.
MY Workers Com nulton Insureyce nmier and Policy number w:
Carrier,S,In' G -I.anral PoRryNo.: OQM`44/47 -Zlad
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This accttm need net hocompleta l ifthe permit is fmanc hundred dollan(SIM)
mist.)
1 sanity that in the performance of the work Im which this permit is issued,I shall net
employ any person In any manner an As an become subject to ma Workers'Compensation
Laws of CaJifnal..Dem
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Esemption,you should
become cabinet in the Workers Compeunlan provision of the Iator Code,you muss
Oforthwith comply with such provisions at this Permit shall be deemed revoked.
z'-' CONSTRUCTION LENDING AGENCY
y
Uj Ther by which thi Net there iso issued
innl.Ch,Agency fm Bx performance.f
ai the work for which this permit ts issued(Sec.]09'1,Civ.CJ
aQ Landers Name
D z Lenders Addrtst
U0 I saaify that I haw mad this application and sum deal the show information is
Dr comm I a{me ta comply with all city and county on inames and sou law mladng in
0 Wilding covwetian,and hereby auoonm mprmmmta6s<s of this city to ensu upon d:
137 above-enentiomd propeny fm inspection purpoes
(We)agree he caw,indemnify and keep harmless the City of Cupertino against
liabiliRu.judgmenu.costs and expenses which may to my way acerod against aid City
U 2 in consequence of the granting of this permit.
F7 APPLICANT UNDERSTANDS AND WILj.COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
ONg. / / �Lf—O
��(/�� Re-roofs
Si{wort ol'Applicauntl2anuescon Dam
HAZARDOUS Wild'
AI.SDISCLOSURE l Type of Roof
Will thea Capetlanfutureii, pmlatommNMle Health
mnd Safety
As defined by Ru Cupertino Municip e,Chapter 9.13.and Lha Health and Safety ,
code,Section 15333(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea u
Will the applicant or future Wilding occupant use equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove
I huaw rdnn air cmummiexas df by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yea
Ihe.mol the huramnusmatanabre33and 55 underCNpmrd.93aftheWilding
deHmlo@Safcry Cad,Sections .tit my responsibility
in
nary
ocupr Wilding /�j/ V/'✓ U ei`
dace not currently haw a tanenl,Net It 4 my responibillly ro nW I'y Ile aneupml of dee
Mqubmcnts which muubomet oroiuu neon canaries er Oceapmey. Signature of Applicant Date
_ /?-- .er c.. 9�zy'-mss
Owner oruthanmdegem pore All roof coverings to be Class��B or better